Bi-directional fixating/locking transvertebral body screw/intervertebral cage stand-alone constructs having a central screw locking lever, and pliers and devices for spinal fusion

ABSTRACT

A bi-directional fixating transvertebral (BDFT) screw/cage apparatus including an intervertebral cage for maintaining disc height, and a method of inserting the same is provided. The intervertebral cage includes a first internal screw guide and a second internal screw guide, a first screw member and a second screw member, and a central screw locking lever coupled to the intervertebral cage, wherein the central screw locking lever prevents the first screw member and the second screw from pulling-out of the first internal screw guide and the second internal screw guide. The central screw locking lever includes a rotatable handle and stem portion, or a screw locking horizontal bracket. A pliers device for inserting and removing the bi-directional fixating transvertebral (BDFT) screw/cage apparatus, a posterior cervical and lumbar facet joint staple, and a staple gun for a posterior cervical and lumbar facet joint staple also are provided.

This application is a continuation of Ser. No. 14/257,650 filed Apr. 21,2014, which is a Divisional Application of Ser. No. 12/471,340 filed May22, 2009, now U.S. Pat. No. 8,734,516 issued May 27, 2014, which is aContinuation-In-Part Application of application Ser. No. 12/054,335filed on Mar. 24, 2008, now U.S. Pat. No. 7,972,363 issued Jul. 5, 2011,which is a Continuation-In-Part of application Ser. No. 11/842,855,filed on Aug. 21, 2007, now U.S. Pat. No. 7,942,903 issued May 17, 2011,which is a Continuation-In-Part of application Ser. No. 11/536,815,filed on Sep. 29, 2006, now U.S. Pat. No. 7,846,188 issued Dec. 7, 2010,which is a Continuation-In-Part of application Ser. No. 11/208,644,filed on Aug. 23, 2005, now U.S. Pat. No. 7,704,279 issued Apr. 27,2010, and this application also claims priority under 35 U.S.C. §119(e)of U.S. Provisional Application No. 60/670,231, filed on Apr. 12, 2005;the entire contents of all of the above identified patent applicationsare hereby incorporated by reference in their entirety.

This application is related to applicants' U.S. Pat. No. 8,257,370issued Sep. 4, 2012, titled “POSTERIOR CERVICAL AND LUMBARINTERARTICULATING JOINT STAPLES, STAPLING GUNS, AND DEVICES FOR SPINALFUSION”, Attorney Docket No. 3003/0107PUS3, which is incorporated hereinby reference.

FIELD OF DISCLOSURE

The present invention relates to a unique universal bi-directional screw(BDS) system, and in particular its application to the spine, alsoreferred to as bi-directional fixating transvertebral (BDFT) screw/cageconstructs which can be used as stand-alone intervertebral devices whichcombine the dual functions of an intervertebral spacer that can befilled with bone fusion material(s), as well as a bi-directionaltransvertebral bone fixating/fusion screw apparatus. In the posteriorlumbosacral and thoracic spine, intervertebral cage/BDFT screwconstructs can be used as stand-alone devices obviating the need forpedicle screw fixation in many but not all cases. In the anteriorcervical, thoracic and lumbosacral spine, intervertebral cage/BDFT screwconstructs can be used as stand-alone devices obviating the need foranterior or lateral (thoracic) spinal plating, and/or supplementalposterior pedicle screw fixation.

The present invention also relates to percutaneous stand-alone orsupplemental posterior cervical, thoracic and lumbosacral calibratedintrerarticulating joint staple guns and staples which may obviateand/or lessen the need for posterior supplemental pedicle screwfixation.

BACKGROUND

The history and evolution of instrumented spinal fusion in the entirehuman spine has been reviewed in related applications Ser. No.12/054,335 filed on Mar. 24, 2008, Ser. No. 11/842,855, filed on Aug.21, 2007, Ser. No. 11/536,815 filed on Sep. 29, 2006, and Ser. No.11/208,644 filed on Aug. 23, 2005, the contents of which are herebyincorporated by reference in their entirety. Conventionally, themajority of posterior cervical and almost all posterior thoracic andlumbosacral fusion surgical techniques are typically supplemented withpedicle screw placement. Conventionally, the majority of anteriorcervical spinal fusions, and many anterio-lateral thoracic, and anterioror anterio-lateral lumbosacral fusions are supplemented with anterior oranterior-lateral spinal plating, and very often, in particular in thethoracic and lumbosacral spine, are supplemented with posterior pediclescrew instrumentation.

Complications of pedicle screw placement in cervical, thoracic andlumbosacral spine include duration of procedure, significant tissuedissection and muscle retraction, misplaced screws with neural and/orvascular injury, excessive blood loss, need for transfusions, prolongedrecovery, incomplete return to work, and excessive rigidity leading toadjacent segmental disease requiring further fusions and re-operations.Recent advances in pedicle screw fixation including minimally invasive,and stereotactic CT image-guided technology, and the development offlexible rods, imperfectly address some but not all of these issues.

Complications of anterior plating in the cervical spine includepotential plate, and/or screw esophageal compression, and misplacedscrews leading to neurovascular injury. Complications of anteriorplating in the anterior lumbar spine include potential devastatinginjury to the major vessels due to chronic vascular erosion of the majorvessels, or acute vascular injuries due to partial or complete plateand/or screw back out. Furthermore, for re-do surgeries, plate removalcan be arduous, with potential complications of prolonged esophagealretraction, vascular injury and screw breakage. Recent advancesincluding diminishing the plate width and/or profile, and absorbableplates, imperfectly address some but not all of these issues.

Complications of all conventional spinal anterior intervertebral deviceconstructs are their potential for extrusion in the absence of plating.Hence, they are supplemented with anterior plating to prevent extrusion.Complications of posterior lumbosacral intervertebral device constructin the presence or absence of supplemental pedicle screw fixation isdevice extrusion, and potential nerve root injuries related toretraction.

SUMMARY

Herein described are multiple device embodiments which combine in asingle stand-alone construct the dual functions of: a) an intervertebralcage spacer which can be filled with bone fusion material maintainingdisc height, and, b) a bi-directional fixating/fusion transvertebralbody screw apparatus. These embodiments are described for posterior andanterior lumbar (and anterio-lateral thoracic) intervertebral placement,and anterior cervical intervertebral placement. The present inventionrecognizes the aforementioned problems with conventional apparatus andsolves these problems by, among other things, improving upon the designsillustrated in the aforementioned related applications. The presentapplication provides an advanced and novel bi-directional fixatingtransvertebral (BDFT) screw/cage apparatus having, for example, moreadvanced screw locking embodiments that prevent screw pull-out orback-out.

The exemplary embodiments of a bi-directional fixating transvertebral(BDFT) screw/cage apparatus provide as strong or stronger segmentalfusion as pedicle screws without the complications arising from pediclescrew placement, which include misplacement with potential nerve and/orvascular injury, violation of healthy facets, possible pedicledestruction, blood loss, and overly rigid fusions. By placing screwsacross the intervertebral space from vertebral body to vertebral body,engaging anterior and middle spinal columns and not the vertebral bodiesvia the transpedicular route thereby excluding the posterior spinalcolumn, then healthy facet joints, if they exist, are preserved. Becausethe present invention accomplishes both anterior and middle columnfusion, without rigidly fixating the posterior column, the presentinvention in essence creates a flexible fusion.

The present invention recognizes that the very advantage oftranspedicular screws which facilitate a strong solid fusion by rigidlyengaging all three spinal columns is the same mechanical mechanismwhereby complete inflexibility of all columns is incurred therebyleading to increasing rostral and caudal segmental stress which leads toan increased rate of re-operation.

Transvertebral fusion also leads to far less muscle retraction, bloodloss and significant reduction in O.R. time. Thus, the complication ofpedicle screw pull out, and hence high re-operation rate associated withthe current embodiment of flexible fusion pedicle screws/rods isobviated. The lumbosacral intervertebral cage/BDFT screw constructs canbe introduced via posterior lateral, transforaminal or anteriorinterbody fusion approaches/surgical techniques. Although one can opt tosupplement these constructs with transpedicular screws there would be noabsolute need for supplemental pedicle screw fixation with theseoperative techniques.

The anterior placement of a bi-directional fixating transvertebral(BDFT) screw/cage apparatus according to the embodiments of the presentinvention into the cervical and lumbar spine obviates the need forsupplemental anterior cervical or anterior lumbar plating. The solepurpose of these plates is to prevent intervertebral device extrusion.This function is completely obviated and replaced by the dualfunctioning bi-directional fixating transvertebral (BDFT) screw/cageapparatus, according to the present invention. The obvious advantage ofthis is a significant savings in operative time, and prevention ofinjuries associated with plating, in particular esophageal, large andsmall vessel injuries, and spinal cord nerve root injuries.

Because the embodiments of the bi-directional fixating transvertebral(BDFT) screw/cage apparatus engage a small percentage of the rostral andcaudal vertebral body surface area, multi-level fusions can be performedwith these devices.

The aforementioned related applications described a novel calibratedlumbar/thoracic stapling device which staples the inferior articulatingfacet of the superior spinal segment to the superior articulating facetof the inferior vertebral segment unilaterally or bilaterally, which mayminimize motion until interbody fusion occurs. The present inventionpresents an evolved and lumbar staple gun which is far more userfriendly than previously described embodiments by incorporating a newrelease mechanism, as described in the aforementioned relatedapplications. This new change simplifies the earlier design, andfacilitates easier insertion and removal of the staple decreasing therisk of the staple becoming loose or falling off during an operation.The exemplary staple gun thus makes posterior lumbar facet stapling farmore amenable for percutaneous fluoroscopically guided surgicalstapling.

The aforementioned related applications introduced a novel posteriorcervical facet stapling device which staples the inferior articulatingfacet of the superior cervical segment with the superior articulatingfacet of the inferior cervical segment either unilaterally orbilaterally. The advantage of cervical facet staples is speed andsafety. The risks of cervical facet pedicle screw fixation, whichinclude nerve root and vertebral artery injuries, are completelyobviated by the use of the embodiments of the present invention. Thus,cervical facet staples achieve the same function of cervical pediclescrews without the risks.

Placement of different embodiments of the cervical facet staples whichinclude those with two or four prongs, along unilateral and/or bilateralfacet joints in a modular manner, lead to different degrees ofcalibrated joint motion hence introducing the novel concept ofcalibrated cervical fusion. In the related applications, cervical facetembodiments of a highly evolved cervical staple gun for the two and fourpronged cervical staples were introduced. The staple gun included abuilt-in trigger, trigger spring, spring hook, and return springpolyethylene cushion that improved the strength, ease and speed ofstaple bone penetration. In this application, the embodiments canprovide more simplified and economically efficient staple guns which arevery user friendly and further enhances the application of the cervicalstaple gun also making posterior cervical facet stapling more amenableto a non-invasive, percutaneous surgical procedure.

Conventionally, failed anterior lumbar arthroplasties are salvaged bycombined anterior and posterior fusions. Intervertebral cage/BDFT screwconstructs may be utilized as a one-step salvage mechanism forfailed/extruded anteriorly placed lumbar artificial discs obviating theneed for supplemental posterior pedicle screws and/or anterior lumbarplating thereby significantly reducing and/or eliminating co-morbiditiesassociated with these other salvage procedures.

Likewise, anterior cervical intervertebral cage/BDFT screw constructplacement can be used to salvage failed anterior cervicalarthroplasties, and re-do fusions without having to supplement withcervical anterior plates, thereby reducing the morbidity of thisprocedure.

In addition, if a patient develops a discogenic problem necessitatinganterior cervical discectomy and fusion at a level above or below apreviously fused and plated segment, the present invention reduces oreliminates the need to remove the prior plate in order to place a newsuperior plate, because the function of the plate is replaced by thedual functioning intervertebral cervical construct, thereby reducing theoperating room time and surgical morbidity of this procedure.

Furthermore, because of the orientation and length of the BDFT screwswithin the intervertebral cage/BDFT constructs, multiple level fusionscan be easily performed. Posterior cervical and lumbar stapling can alsobe performed for multiple levels.

For example, an exemplary embodiment is directed to an intervertebralcage spacer and bi-directional fixating/fusion transvertebral bodyscrew/cage apparatus, a posterior lumbar facet staple and a staple gunfor a posterior lumbar facet staple, and a staple gun for a posteriorcervical facet joint staple are provided. The apparatus includes anintervertebral cage for maintaining disc height. The intervertebral cageincludes a first internal screw guide and a second internal screw guide.The apparatus further includes a first screw member having a tapered endand a threaded body disposed within the intervertebral cage, a secondscrew member having a tapered end and a threaded body disposed withinthe intervertebral cage, The device includes a novel mechanism involvinga separate screw locking bracket with hooks that insert into aprefabricated insertion site within the sides of the intervertebral cagewhich when press-fit onto the cage prevents the screw members frompulling-out of the internal screw guides. A specifically designed set ofpliers is illustrated which can be used to insert the locking brackets.The tips have stops so that the brackets can be more easily held. Italso has a limiting screw to limit the amount the pliers close toprevent over-pressing the locking brackets. It also has a leaf springthat preloads the pliers. These appliers can also apply gentle pressureon the brackets flexure grips (side tabs) to slightly deform (open) thebracket hooks, thus easily removing the bracket if necessaryintra-operatively or in the future.

Another exemplary embodiment is directed to a staple gun for a posteriorlumbar facet joint staple gun, including a handle having a first gripand a second grip, a cylinder body having a first end for receiving theposterior lumbar facet joint staple and a second end adjacent to thehandle, a connector that connects the cylinder body to the handle, apuller, an independent puller tip and a return spring. This embodimentis more user friendly making the staple gun easier to load, easier touse, and prevents the staple from falling off during any portion of thesurgery.

Yet another exemplary embodiment is directed to a staple gun for aposterior cervical facet joint staple, including a handle, a retainingspring, a central plunger and a tip. The device can be used with ahammer to apply two or four pronged posterior cervical staples to impactthem into the facets. A central button releases the staple from thespring allowing the staple gun to be reloaded.

Another exemplary embodiment is directed to a method of inserting abi-directional fixating transvertebral (BDFT) screw/cage apparatusbetween a first vertebral body and a second vertebral body. The methodincludes measuring a dimension of a disc space between the firstvertebral body and the second vertebral body, determining that the discspace is a posterior lumbar disc space, an anterior lumbar disc space,or an anterior cervical disc space, selecting an intervertebral cagebased on the measured dimension of the disc space and based on thedetermination of the disc space being the posterior lumbar disc space,the anterior lumbar disc space, or the anterior cervical disc space,inserting the selected intervertebral cage into a midline of the discspace until the selected intervertebral cage is flush or countersunkrelative to the first vertebral body and the second vertebral body,inserting a first screw member into a first internal screw guide of theselected intervertebral cage, inserting a second screw member into asecond internal screw guide of the selected intervertebral cage,screwing the first screw member and the second screw member into thefirst vertebral body and the second vertebral body respectively,confirming a position and placement of the intervertebral cage relativeto the first vertebral body and the second vertebral body, and lockingthe first screw member and the second screw member in a final positionby embedding a portion of the first screw member and the second screwmember into a screw locking mechanism of the selected intervertebralcage.

Once the surgeon is satisfied with the position and placement of thecage, the screws can then be locked in their final positions. Then ascrew locking bracket is applied with the special plier tool on top ofthe cage allowing the bracket hooks to snap into the cage inserts. Ifthe surgeon changes his mind intra-operatively, or if in a future datethe construct needs to be removed, the surgeon presses on the side tabswith a pliers embodiment to slightly deform (open) the bracket hooks andcan then easily remove the locking bracket. Multiple level placementscan be performed including two, three or more levels if necessary.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings are presented to aid in the description ofembodiments of the invention and are provided solely for illustration ofthe embodiments and not limitation thereof.

FIGS. 1A-E illustrate an embodiment of an anterior cervicalintervertebral cage/BDFT screw construct with a central screw lockinglever in top (FIG. 1A), bottom isometric (FIG. 1B), side (FIG. 1C),isometric front (FIG. 1D), isometric bottom, and isometric fullyexploded with visualized internalized angled screw guides (FIG. 1E)views.

FIGS. 2A-D illustrate an embodiment of an intervertebral cage/BDFT screwconstruct with screw locking bracket in top (FIG. 2A), bottom isometric(FIG. 2B), side isometric (FIG. 2C), top isometric fully explodes withvisualized internal screw guides (FIG. 2D), and bottom isometric fullyexploded with visualized bracket hooks and flexion grips (FIG. 2E)views.

FIGS. 3A-F illustrate an embodiment of an anterior lumbar intervertebralcage/BDFT screw construct with screw locking bracket in top (FIG. 3A),bottom (FIG. 3B), front (FIG. 3C), side (FIG. 3D), isometric top fullyexploded with visualized internalized angled screw guides (FIG. 2E), andisometric fully exploded with visualized bracket hooks and flexion grips(FIG. 3F) views.

FIGS. 4A-F illustrate an embodiment of a posterior lumbar intervertebralcage/BDFT construct with screw locking bracket in top (FIG. 4A), front(FIG. 4B), side (FIG. 4C), isometric (FIG. 4D), isometric fully explodedwith visualized internalized angled screw guides (FIG. 4E), andisometric fully exploded with visualized bracket hooks and flexion grips(FIG. 4F) views.

FIG. 5 illustrates a pliers embodiment which applies the locking bracketto and also removes it from the intervertebral cage/BDFT constructs.

FIGS. 6A-D illustrate an embodiment of a Lumbar facet joint staple gunin side view (FIG. 6A), exploded (FIG. 6B) and cross-sectional (FIG. 6C)and front-on (FIG. 6D) view.

FIGS. 7A-E illustrate an embodiment of a posterior cervical facet staplegun in side view (FIG. 7A), oblique (FIG. 7B), exploded (FIG. 7C),cross-sectional (FIG. 7D), and front-on (FIG. 7E) views.

FIGS. 8A-E illustrate another embodiment of a posterior cervical facetstaple gun in side view (FIG. 8A), oblique (FIG. 8B), exploded (FIG.8C), cross-sectional (FIG. 8D), and front-on (FIG. 8E) views.

FIGS. 9A-B illustrate an embodiment of a posterior lumbar facet staple,flexure spring embodiment in side isometric (FIG. 9A) and exploded (FIG.9B) views.

FIGS. 10A-C illustrate an embodiment of a posterior lumbar facet staple,torsional spring embodiment in side isometric (FIG. 10A), bottomisometric (FIG. 10B), and exploded (FIG. 10C) views.

DETAILED DESCRIPTION

Aspects of the invention are disclosed in the following description andrelated drawings directed to specific embodiments of the invention.Alternate embodiments may be devised without departing from the scope ofthe invention. Additionally, well-known elements of the invention willnot be described in detail or will be omitted so as not to obscure therelevant details of the invention.

The word “exemplary” is used herein to mean “serving as an example,instance, or illustration.” Any embodiment described herein as“exemplary” is not necessarily to be construed as preferred oradvantageous over other embodiments. Likewise, the term “embodiments ofthe invention” does not require that all embodiments of the inventioninclude the discussed feature, advantage or mode of operation.

With reference to FIGS. 1A-10C, exemplary embodiments of the inventionwill now be described.

1. The Medical Device

Referring to FIGS. 1-5, the above described problems of the conventionalart can be solved in the cervical, thoracic and lumbosacral spines byinsertion into the denuded intervertebral disc space multipleembodiments of a bi-directional fixating transvertebral (BDFT)screw/cage apparatus.

For example, FIGS. 1A-E illustrate three-dimensional views of anembodiment of an anterior cervical intervertebral cage/BDFT construct10. In this embodiment, the cage is elliptically contoured (FIG. 1C;side view) to fit into the bi-concave cervical disc space. Theembodiment includes two screws 12, 14. A first screw 12 is orientedrostrally (superiorly) and a second screw 14 is oriented caudally(inferiorly). The cage 10 can include a cavity 16 for bone productplacement. The cage 10 includes two built in internalized screw/drillguides 18, 20, one for each screw 12, 14 which orient the screwsbi-directionally in opposite directions. One of ordinary skill in theart will recognize that the internalized screw/drill guides 18, 20 canhave different degrees of angulation and/or different positions withinthe cage 10. The built in tunnels of the screw guides 18, 20 provide animportant advantage of ensuring that only one prescribed angledtrajectory is possible for transvertebral screw placement. Embodimentsof the intervertebral cages 10 can be designed with internalizedscrew/drill guides 18, 20 with different angles and/or differentpositions within the cage 10. The angle and size of the screws 12, 14make them amenable to single or multi-level placement. The superior andinferior surfaces or edges of the lumbar cage 10 can include ridges 22to facilitate integration and fusion with superior and inferiorvertebral bodies.

The embodiment also includes a central screw locking lever 24 which isinserted in between left and right internalized screw/drill/guides 18,20 into the top center of the construct 10 (FIG. 1E). The central screwlocking lever 24 can be manufactured from a variety of materials, suchas titanium. After the screws 12, 14 are fully turned into the construct10, the screw locking lever handle 26 which is initially orientedvertically, is rotated ninety degrees so that the handle 26 covers andlocks both left and right screws 12, 14 thereby preventing back-out Andpull-out. The locking mechanism 24 can be reused for a number of cycles.This locking mechanism 24 is an additional evolutionary embodiment notdescribed in the aforementioned related applications.

For example, an aspect of the invention is directed to bi-directionalfixating transvertebral (BDFT) screw/cage 10 apparatus, comprising anintervertebral cage 10 for maintaining disc height, the intervertebralcage 10 including a first internal screw guide 18 and a second internalscrew guide 20, a first screw member 12 having a tapered end and athreaded body disposed within the intervertebral cage 10, a second screwmember 14 having a tapered end and a threaded body disposed within theintervertebral cage 10, wherein each of the first internal screw guide18 and the second internal screw guide 20 are angled to orient the firstscrew member 12 and the second screw member 14 bi-directionally inopposite directions, wherein the first internal screw guide 18 and thesecond internal screw guide 20 are aligned along a longitudinal axis ofthe intervertebral cage 10, and a central screw locking lever 24 coupledto the intervertebral cage 10, wherein the central screw locking lever24 prevents the first screw member 12 and the second screw member 14from pulling-out of the first internal screw guide 18 and the secondinternal screw guide 20.

The central screw locking lever 24 can be rotatably coupled to theintervertebral cage 10. The central screw locking lever 24 can include ahandle portion 26, and a stem portion 28 extending from a lower side ofthe handle portion 26, the stem portion 28 being substantiallyperpendicular to the lower side of the handle portion 26. The centralscrew locking lever 24 can be rotatable about an axis of the stemportion 28.

The central screw locking lever 24 can be rotatable between an unlockedposition in which the handle portion 26 is transverse to thelongitudinal axis of the intervertebral cage 10, and a locked positionin which the handle portion 26 extends along the longitudinal axis ofthe intervertebral cage 10.

The first screw member 12 and the second screw member 14 are exposedwhen the handle portion 26 is in the unlocked position, and the handleportion 26 of the central screw locking lever 24 covers and locks thefirst screw member 12 and the second screw member 14 in theintervertebral cage 10 when the handle portion 26 is in the lockedposition. The central screw locking lever can be a T-shaped screwlocking lever 24. A top face of the intervertebral cage 10 can includean opening for engaging the central screw locking member 24. The opening29 can be formed between the first internal screw guide 18 and thesecond internal screw guide 20. The central screw locking lever 24 caninclude a first threaded portion and the opening 29 can include acorresponding second threaded portion, and wherein the central screwlocking lever 24 is threaded into the opening 29 of the intervertebralcage 10 by engaging the first threaded portion of the central screwlocking lever 24 with the second threaded portion of the opening. Thecentral screw locking lever 24 can be press-fit into the opening 29 ofthe intervertebral cage 10. The central screw locking lever 24 can bemade of titanium.

FIGS. 2A-E depict another screw locking mechanism for anterior cervicalcage/BDFT constructs. This locking mechanism is a screw lockinghorizontal bracket 30 which snaps on to the top of the construct 10 oncethe screws 12, 14 have been maximally turned thereby preventing screwpull-out or back-out. The screw locking bracket 30 is designed with leftand right bracket hooks 34. They are inserted into hook insertion slots36 which are prefabricated on the left and right sides of the cageconstruct 10 to precisely snugly fit the bracket hooks 34. Once thebracket hooks 34 are inserted into the cage insertion slots 36, thebracket 30 cannot be dislodged. In order to remove the bracket 30; if itbecomes necessary to remove the cage 10 at some future time, flexiongrips (side tabs) 32 have been designed on the bracket 30. The lockingbracket 30 can be applied to the construct 10 with the speciallydesigned pliers (exemplarily described with reference to FIG. 5) whichpress fit the bracket 30 onto the cage 10 thereby locking the screws 12,14. In order to remove the bracket 30, the user needs only to press onthe side tabs 32 with the pliers (FIG. 5) to slightly deform (open) thebracket hooks 34, and thereby easily remove the bracket 30.

The novel embodiments of the present invention are quite unique anddifferent from all other conventional locking mechanisms used for othertypes of anterior cervical plates. No other conventional anteriorcervical intervertebral cage/BDFT screw constructs are known.

For example, an exemplary aspect of the invention is directed to acentral screw locking lever 24 can include a screw locking horizontalbracket 30. The screw locking horizontal bracket 30 can be press fit ona top of the intervertebral cage 10 and covers and locks the first screwmember 12 and the second screw member 14 in the intervertebral cage 10.The screw locking horizontal bracket 30 can include a cover portionextending in a direction of the longitudinal axis of the intervertebralcage 10 and substantially parallel to a top face of the intervertebralcage 10, the cover portion covering and locking the first screw member12 and the second screw member 14 in the intervertebral cage 10, andside tabs 32 on each end of the cover portion, wherein the side tabs 32extend in a direction perpendicular to the cover portion along the sidesof the intervertebral cage 10. The side tabs 32 include bracket hooks 34extending from the side tabs 32 toward the sides of the intervertebralcage 10 and in a direction of the longitudinal axis of theintervertebral cage 10. The intervertebral cage 10 can include one ormore slots 36 for lockingly engaging a part of the screw lockinghorizontal bracket 30. The sides of the intervertebral cage 10 includehook insertion slots 36, and wherein the bracket hooks 34 engage thehook insertion slots 36. The bracket hooks 34 lockingly engage the hookinsertion slots 36. The side tabs 32 of the screw locking horizontalbracket 30 include bracket flexion grips. The screw locking horizontalbracket 30 can be deformable. The screw locking horizontal bracket 30can be deformable under pressure applied to the bracket flexion grips.The bracket hooks 34 include flexible bracket hooks.

FIGS. 3A-F illustrate three-dimensional views of an embodiment of ananterior lumbar intervertebral cage/BDFT construct. In this embodiment,the cage 10 is larger than the cervical cage and is also ellipticallycontoured to fit into the bi-concave lumbar disc space (FIG. 3D; sideview). The cage 10 includes four (4) horizontally aligned internalizedscrew guides 18, 19, 20, 21 for four (4) screws 12, 13, 14, 15. The twolateral (left and right) screws are oriented inferiorly, and the twomiddle screws are oriented superiorly. In the embodiment, theorientations of the four screw guides 18, 19, 20, 21 (and screws 12, 13,14, 15) are selected because of their symmetry and inherent stability.The cage 10 can include a large cavity 16 for bone product placement.The cage 10 includes four built-in internalized screw/drill guides 18,19, 20, 21, one for each screw. Other embodiments of the intervertebralcage 10 can be designed with internalized screw/drill guides 18, 19, 20,21 with different angles and/or different positions within the cage 10.The angle and size of the screws make them amenable to single ormulti-level placement. The superior and inferior surfaces or edges ofthe cage 110 can include ridges 22 to facilitate integration and fusionwith superior and inferior vertebral bodies. In this embodiment, thereare no compartmental divisions in the cavity 16 for bone productplacement to maximize the quantity of bone for fusion.

FIGS. 3A-F depicts a screw locking embodiment for anterior thoracic andLumbosacral cage/BDFT constructs. This locking mechanism is a screwlocking horizontal bracket 30 which snaps on to the top of the constructonce the four screws 12, 13, 14, 15 have been maximally turned therebypreventing screw pull-out or back-out of all four screws 12, 13, 14, 15simultaneously. The screw locking bracket 30 is designed with left andright bracket hooks 34. They are inserted using the specially designedpliers (FIG. 5) into hook insertion slots 36 which are prefabricated onthe left and right sides of the cage construct to precisely snugly fitthe bracket hooks 34. Once the bracket hooks 34 are inserted into thecage insertion slots 36, the bracket 30 cannot be dislodged. In order toremove the bracket 30; if it might become necessary to remove the cage10 at some future time, flexion grips (side tabs) 32 have been designedon the bracket 30. The locking bracket 30 is the press fit by the pliers(FIG. 5) onto the cage 10 in order to lock the screws 12, 13, 14, 15. Inorder to remove the bracket 30, the user needs only to press on the sidetabs 32 with the pliers (FIG. 5) to slightly deform (open) the brackethooks thereby easily removing the bracket 30.

Another identical locking mechanism embodiment which includes a centralrotating locking lever mechanism as designed for the cervical cage. BDFTconstructs can likewise be designed for the anterior thoracic andlumbosacral cage/BDFT constructs. These novel locking mechanisms alsoare quite unique and different from all other conventional lockingmechanisms used for other types of anterior lumbar cages.

Another patent which mentions anterior placed lumbar implants withperforating screws includes U.S. Pat. No. 4,904,261 (John Dove, PhilipH. Hardcastle, John K. Davis and Brian King). The '261 patent disclosesa horseshoe implant having a plurality of cylindrical holes with smoothinner surfaces and comprise only one stop for the heads of the bonescrews to be inserted into them. The placement of five cylindrical holesis oriented within the cage in a non-symmetric manner.

In comparison, the embodiments of the present invention differ in manysubstantial ways from the conventional devices. For example, the presentinvention provides a symmetric orientation of the screw holes, as wellas completely novel and unique screw locking mechanism (e.g., 24, 30,etc.). The present invention also describes an angulation/trajectory(e.g., a preferred angulation/trajectory) for preventing pull-out orback-out of the screws that would make placement of all screws in amanner which would lead to maximum stability of the construct within thevertebral space, and obviate the need for external drill guides, andsurgeon trajectory angulation guess work.

In another patent U.S. Pat. No. 7,232,464 B2 (Claude Mathieu andChristopher Marden John Cain) multiple embodiments of lumbarintervertebral implants are presented which include one with internallythreaded bore holes, another embodiment with a front plate mounted atthe front surface of the implant, and another embodiment with the frontplace displaceably configured to move vertically relative to theimplant. In addition, the disclosed preferred borehole axes are 35-55degrees. The '464 patent has four screw perforations that are notaligned four in a row. Two of the screw holes are laterally placed onthe left, one on top of each other, the top one with a superiortrajectory, and the bottom with an inferior trajectory. Likewise, twoperforations are placed on the right, one on top of each other, the topone with a superior trajectory and the bottom one with an inferiortrajectory. The disclosed screw locking mechanism is a screw with anexternal thread matching the internal borehole thread, or spiralsprings.

In comparison, the anterior lumbar construct of the present inventiondiffers in many substantial ways from the conventional devices. Thepresent invention includes a single cage construct with four (4)internalized drill guides 18, 19, 20, 21 arranged horizontally in a row.The middle two screws are oriented superiorly, and the lateral left andright screws are oriented inferiorly. This symmetric alignment of screwsand orientations within the superior and inferior vertebral bodies(e.g., two middle superiorly projecting screws, and two laterallyprojecting inferior screws) make the fixation to the superior andinferior vertebral bodies much more symmetric and thus more stable. Inan embodiment of the present invention, the cage includes a screw guidehaving a predetermined trajectory (e.g., a preferred trajectory of 25degrees) that makes placement of all screws equally facile, moreamenable to multi-level placement, and diminishes the need for externaldrill guides. Furthermore, the exemplary screw locking mechanisms areunique and differ substantially from the conventional approach ofmatching screw/cage threads or spiral springs.

FIGS. 4A-F illustrate three-dimensional views of an embodiment of aposterior lumbar intervertebral cage/BDFT construct. In this embodiment,the screws perforate and orient in opposing superior and inferiordirections. The cage 10 can include a cavity 16 for bone productplacement. The top and bottom portions of the cage 10 are ellipticallycontoured to naturally fit into the bi-concave intervertebral disc space(FIG. 4C; side view). The cage 10 includes built-in internalizedscrew/drill guides 18, 19 having a predetermined angled trajectory. Oneof the guides is angled rostrally (superiorly) (e.g., guide) and theother caudally (inferiorly) (e.g., guide). The intervertebral cages canbe designed with internalized screw/drill guides 18, 19 with differentangles and/or different positions within the cage 10. The angle and sizeof the screws 12, 14 make them amenable to single or multi-levelplacement. The superior and inferior surfaces or edges can includeridges 22 to facilitate integration and fusion with superior andinferior vertebral bodies. One of these constructs is placed posteriorlyinto the intervertebral space on the left side, and the other on theright side.

The cage 10 includes a screw locking mechanism for posterior lumbosacralcage/BDFT constructs. This locking mechanism is a screw lockinghorizontal bracket 30 which snaps on to the top of the construct oncethe screws have been maximally turned thereby preventing screw pull-outor back-out. The screw locking bracket 30 is designed with left andright bracket hooks 34. They are inserted into hook insertion slots 36which are prefabricated on the left and right sides of the cageconstruct to precisely snugly fit the bracket hooks 34. Once the brackethooks 34 are inserted into the cage insertion slots 36 using thespecially designed pliers (FIG. 5), the bracket 30 cannot be dislodged.In order to remove the bracket 30; if it becomes necessary to remove thecage 10 at some future time, flexion grips (side tabs) 32 have beendesigned on the bracket 30. The locking bracket 30 can be press fit ontothe cage 10 using the pliers (FIG. 5) thereby locking the screws 12, 14.In order to remove the bracket 30, the user needs only to press on theside tabs 32 with the pliers (FIG. 5) to slightly deform (open) thebracket hooks 34, and thereby easily remove the bracket 30.

The screw locking bracket 30 can be manufactured from a variety ofmaterials, such as titanium. It can be reused for a number of cycles.

As illustrated in FIG. 5, a pliers device 40 for inserting and removingthe locking mechanism can include a first arm rotatably coupled to asecond arm; wherein each of the first arm and the second arm includes ahandle portion on a first end; wherein the first arm includes an upperplier tip 42 and the second arm includes a lower plier tip 44, andwherein the first arm and the second arm engage the central screwlocking lever 30. The upper plier tip 42 and the lower plier tip 44 eachinclude a stop 46 configured to engage the bracket flexion grips 32. Thepliers 40 can include a leaf spring 48 between the first arm and thesecond arm, wherein the leaf spring 48 biases the first handle portionaway from the second handle portion. The pliers 40 can include a limiter50 and limiting screw 52.

In an aspect of the pliers device 40 for inserting and removing abi-directional fixating transvertebral (BDFT) screw/cage apparatus, thepliers device comprises a first arm rotatably coupled to a second arm;wherein each of the first arm and the second arm includes a handleportion on a first end; wherein the first arm includes an upper pliertip 42 and the second arm includes a lower plier tip 44, wherein thefirst arm and the second arm engage the bracket flexion grips 32,wherein the upper plier tip 42 and the lower plier tip 44 each include astop 46 configured to engage the bracket flexion grips 32, and a leafspring 48 between the first arm and the second arm, wherein the leafspring 48 biases the first hand portion away from the second handleportion.

Another identical locking mechanism embodiment which includes a centralrotating locking lever mechanism as designed for the cervical, thoracicand lumbosacral cage/BDFT constructs can likewise be designed for theposterior lumbosacral cage/BDFT constructs.

The exemplary embodiments of these locking mechanisms are anotherevolutionary embodiment not illustrated in the aforementioned relatedapplications. The novel locking mechanisms are also is quite unique anddifferent from other conventional locking mechanisms used for otherknown cervical and lumbar anterior or posterior plate screws. No otherconventional posterior lumbar intervertebral cage BDFT/screw constructsare known.

FIGS. 6A-6D illustrate an embodiment of a lumbar facet joint staple gun.

Features of lumbar facet joint staple guns have been thoroughlydescribed in the aforementioned related applications, the relevantportions of which are hereby incorporated by reference in theirentirety. The exemplary staple gun 400 is an evolutionary advancedversion compared to the conventional designs. The changes incorporatedherein facilitate easier insertion and removal of the staple 700compared to our prior design. An improved feature of the staple gun isthe design of an independent puller tip which can be swung open when thestapler is at its maximum open position.

The figures illustrate the staple gun 400 which includes two upper andlower grips 404, 406, upper and lower bars 408, 410, a cylinder 418, apuller 414, a puller tip 402, a connector 418, a return spring 420, andpins 422.

In our previous design the user might have to force the staple hinge tofit into the loops (puller), and once the staple 700 was closed the userhad to pry the staple hinge from the loops. To address this problem, oneof the loops was made as an independent part which can be swung openwhen the stapler is at its maximum open position.

The following is the mechanism of its action: The user opens the staplerhandles to their maximum. This forces the puller part 414 to stick outfrom the cylinder part 412. In that configuration, the puller tip 402can be opened, and the user can insert the staple 700, and close thepuller tip 402 (no force required). As the user closes the staplehandles, the puller part 414 retracts into the cylinder part 412 whichprevents the puller tip part 402 from opening. Thus there is no risk ofthe staple 700 becoming loose or falling off during surgery. Once thestaple 700 has been closed, and is locked, the user can open once morethe staple handles to their max to force the puller part out, and inthat configuration, the puller tip 402 can be opened, and the staple 700can be released. The release mechanism doesn't have a spring. The pullertip 402 can simply be opened only when the center shaft (puller) isextended completely. When the puller 414 is retracted (during stapling)the release (puller tip) is constrained by the surrounding geometry i.e.it cannot move. The main advantage of this mechanism is its simplicity.The spring 420 is for the return. The spring 420 pushes the puller out,so after the user staples, by pressing the handles together and pullingthe center shaft in (puller), the spring 420 will force the puller 414out and swing the handles open to reset the stapler.

For example, an aspect of the invention can include a staple gun for alumbar facet joint staple includes a handle having an upper bar 408 anda lower bar 410, each of the upper bar 408 and the lower bar 410 havinga first and a free end, a hollow cylinder 412 body having a first endfor receiving the lumbar facet joint staple and a second end adjacent tothe handle, a connector 418 having a first end coupled to the hollowcylinder 412 body and a second end coupled to the handle such that thefirst end of each of the upper bar 408 and the lower bar 410 can bepivotably coupled to the connector 418, a puller 414 disposed in andextending through the hollow cylinder 412 body, wherein the puller 414has a first end for receiving the lumbar facet joint staple and a secondend adjacent to the handle, the second end of the puller 414 beingcoupled to the handle, and a puller tip 402 coupled to the first end ofthe puller 414, wherein the handle can be moveable from a closedposition to an open position, a distance between the free end of theupper bar 408 and the free end of the lower bar 410 in the closedposition being less than a distance between the free end of the upperbar 408 and the free end of the lower bar 410 in the open position,wherein the first end of the puller 414 and at least a part of thepuller tip 402 are disposed inside the first end of the hollow cylinder412 body when the handle is in the closed position, and wherein thefirst end of the puller 414 and at least a part of the puller tip 402extend outside the first end of the hollow cylinder 412 body when thehandle is in the open.

The puller tip 402 can be moveable between an open position and a closedposition when the handle in the open position, and wherein the pullertip 402 is locked in the closed position by the first end of the hollowcylinder 412 body when the handle in the closed position. The puller tip402 can include a first loop part and a second loop part, the first looppart and the second loop part for grasping sides of the lumbar facetjoint staple, wherein the first loop part is movable with respect to thesecond loop part in a direction transverse to a longitudinal axis of thepuller 414. The staple gun can include a spring return mechanism thatbiases the handle in the open position. The handle can include a linkagecoupling the puller 414 to each of the upper bar 408 and the lower bar410.

Features of cervical facet joint staples have been thoroughly describedin the aforementioned related applications, the relevant portions ofwhich are hereby incorporated by reference in their entirety.

As shown in FIGS. 7A through 8E, an exemplary posterior cervical facetjoint staple 702 includes a staple body extending along a longitudinalaxis. The body includes a plurality of prongs extending from a lowersurface of the staple body. The lower surface of the staple body alsoincludes a groove for engaging or fitting into the spring supports of astaple gun (e.g., a cervical staple gun, as described in more detailbelow). The groove extends along an axis that is perpendicular to thelongitudinal axis of the staple body. The groove is disposed at a centerpoint along the longitudinal axis.

FIGS. 7 and 8 illustrate a four-prong embodiment. The cervical staplegun embodiments can also be used for a two pronged staple embodiment.

More particularly, the lumbar staple has top and bottom claws which cometogether. The top part of the staple, beneath from where the stapleprongs come out, has on either side, a circular protuberance with a holein the center. A pin goes through this hole and through a hole in thelower staple claw thus connecting these two components which pivotaround the pin to open and close the jaw of the staple. Theprotuberances on both sides of the staple can be fit snugly into thepuller tip 402 of the staple gun.

Exemplary aspects of a staple are illustrated in FIGS. 9A-B and 10A-C.

FIGS. 9A-B illustrate an embodiment of a posterior lumbar facet staplehaving a flexure spring. FIGS. 10A-C illustrate an embodiment of alumbar facet staple having a torsional spring. Features of a lumbarfacet staple have been thoroughly described in the aforementionedrelated applications, the relevant portions of which are herebyincorporated by reference herein in their entirety. The embodimentsillustrated in the related applications included a ratchet. The staplecould be incrementally closed with increased ratcheting over increasingnumber of spurs. The present invention provides two evolved embodiments,which are superior to conventional designs in that the closingmechanisms can withstand much greater force (Newtons) than a smallexternal ratchet. Other improvements will be described below.

FIGS. 9A-B illustrate an embodiment of a posterior lumbar facet staple500 having a flexure spring 530. As shown in FIGS. 9A-B, the features ofthe staple 500 include top claws 510 and bottom claws 520 with ridges570 to help incorporate and fuse with bone. A staple pin (pivot) 560connects the top claws 510 and bottom claws 520. The staple 500 includesfour fastener pins (prongs) 580, 582, 584, 586, two per top claw 510 orbottom claw 520. Ratchet teeth 540 are molded onto the lower claw 520,and a spring loaded ratchet pawl 530 pivots on the claw, and locks thestaple 500 in position. As the staple 500 closes, the ratchet 540 worksin standard fashion. When a force is applied to open the staple 500, theratchet 540 locks up, but the ratchet pawl (e.g., the flexure spring)530 acts as a spring due to its curvature. So depending on the materialused for the ratchet spring, the ratchet spring 530 can deform more orless, thereby providing different degrees of resistance. The ratchetmechanism 540 limits the opening force of the staple 500 by a forceproportional to the stiffness of the flexure spring 530 (e.g., ratchetpawl). The force can be tailored by making the pawl from differentmaterials or varying the dimension of the flexure spring on the pawl.This embodiment can achieve significant rigidity (stiffness).

FIGS. 10A-C illustrate an embodiment of a posterior lumbar facet staple600 having a torsional spring 630. FIGS. 10A-C illustrate features ofthe staple 600, which include top claws 610 and bottom claws 620 withridges 670 to help incorporate and fuse with bone. A staple pin (pivot)660 joins the upper claw 610 and lower claw 620 of the staple 600. Thestaple 600 includes four fastener pins (prongs) 682, 684, 686, 688, twoper top claw 610 or bottom claw 620 of the staple 600. The features ofthe staple 600 include a torsional spring 630, a brake 680, and a pivotspring pin 640. As the staple 600 closes, the ratchet works in standardfashion. When the staple 600 is open, the spring does not interfere withthe motion. Once the staple 600 is closed there is a ratchet mechanism(brake) 680 that engages with the spring 630. At that point, the forcerequired to open the staple 600 will depend on the stiffness of thespring 630. Having staple models with different types of springs (e.g.,soft, hard, etc.) allows the tailoring of different staples to the needsof a given patient. The embodiments of the present invention have lesscompliance than the conventional devices.

The staple gun embodiments illustrated in FIGS. 7 and 8 provide improvedfeatures over those previously described in our prior applications. Theadvantages of both these embodiments are their economic efficiency ofdesign, their simplicity and their amenability to percutaneous surgicalapproaches.

FIGS. 7A-E illustrate an embodiment of a posterior cervical facet staplegun.

The internal mechanism includes a handle 802, a central staple plunger804, a tip 806, and a retaining spring 808. A staple 702 is held inplace at the tip 806 of the staple guide by a retaining spring 808. Thedevice can be used with a hammer to apply a staple 702 (either two orfour pronged). The spring 808 holding the staples 702 in place is abi-staple spring that is opened to release a staple by pressing thecenter button (central plunger) of the handle 802. Pressing the centralbutton opens up the spring 808, and the staple gun can then be reloadedwith another staple 702.

FIGS. 8A-E illustrate another embodiment of a posterior cervical facetstaple gun. The internal mechanism includes a handle 902, a plunger 910,and two mirror retaining springs 908, 909. The staple 702 is held inplace at the tip of the staple guide by the retaining springs 908, 909.The device can be used with a hammer to impact the staple (either two orfour pronged). A center button can be pressed to release the staple whenneeded. The staple gun can then be reloaded with another staple.

2. Surgical Method

Exemplary surgical steps for practicing one or more of the forgoingembodiments will now be described.

Anterior cervical spine placement of the intervertebral cage/BDFT screwconstruct (FIGS. 1-2) can be implanted via previously describedtechniques for anterior cervical discectomy and fusion. Some but not allof these techniques include, open, microscopic, closed endoscopic ortubular. Fluoroscopic or any other form of visualized guidance can beused for this procedure.

After the adequate induction of anesthesia the patient is placed in asupine position. An incision is made overlying the intended disc spaceor spaces, and the anterior spine is exposed. A discectomy is performedand the endplates exposed. The disc height is measured and an anteriorcervical intervertebral cage of the appropriate disc height, width anddepth is selected. The central cavity is packed with bone fusionmaterial, autologous bone graft, allograft, alone or in combination withany commercially available bone fusion promoting product. The cage isthen inserted into the midline of the anterior disc space routinelyuntil it is flush or countersunk relative to the vertebral body aboveand below. The BDFT screws are then inserted into the internalizedrostrally (superiorly) and caudally (inferiorly) angled screw guides. Adrill with or without a drill guide can be used to prepare for screwplacement. This is not absolutely necessary. Because the cage hasinternalized screw guides, self-drilling/self-tapping screws of theappropriately selected lengths can be directly screwed into thevertebral bodies once placed into the internalized drill-guided angledtunnels. The cage's screw guides, which have internalized tunnels,direct the screws into the superior and inferior vertebral bodies in thepredetermined angle of the internalized tunnels. There is no otherangled trajectory other than that which is built into the internalizedscrew guide/tunnel of the cage that the screw can be oriented in. Hence,there is no absolute need for fluoroscopic guidance.

Once the surgeon is satisfied with the position and placement of thecage, the BDFT screws can then be locked into their final positions. Inthe embodiment in FIG. 1, the patient rotates the central locking screwlever from the midline vertical position, ninety degrees; so that thelocking lever handles lock the screws into position preventing screwpull-out. If the surgeon changes his mind intra-operatively or if in afuture date the construct needs to be removed, the screw locking leveris rotated another ninety degrees, unblocking access to the screws, andthe screws can be backed out. The locking mechanism has several cyclesof use, and thus screws once backed out, can be re-screwed andre-locked. Multiple level placements can be performed including two,three or more levels if necessary.

For the embodiment illustrated in FIG. 2, once the surgeon is satisfiedwith the position and placement of the cage, the BDFT screws can then belocked in their final positions. Then a screw locking bracket is gentlyplaced on top of the cage with the pliers (FIG. 5) allowing the brackethooks to snap into the cage inserts. The plier tips have stops so thatthe brackets could be more easily held. It has a limiting screw thatlimits the amount the pliers close to prevent over-pressing the lockingbrackets. It also has a leaf spring that serves to pre-load the pliers.If the surgeon changes his mind intra-operatively, or if in a futuredate the construct needs to be removed, the surgeon presses on the sidetabs with the pliers (FIG. 5) to slightly deform (open) the brackethooks and easily remove it. The locking mechanism has several cycles ofuse, and thus screws once backed out, can be re-screwed and re-locked.Multiple level placements can be performed including two, three or morelevels if necessary.

Anterior or anteriolateral placement of thoracic or lumbar spineintervertebral cage/BDFT screw constructs (FIG. 3) can be implanted viapreviously described surgical techniques for anterior lumbar discectomy,and transthoracic, anterior-lateral thoracic discectomy. Some but notall of these techniques include, open, microscopic, closed endoscopic ortubular. Fluoroscopic or any other form of visualized guidance can beused for this procedure.

After the adequate induction of anesthesia and after the anterior spineis exposed a discectomy is performed and the endplates exposed. The discheight is measured and an anterior lumbar (or thoracic) intervertebralcage of the appropriate disc height, width and depth is selected. Thecentral cavity is packed with bone fusion material, autologous bonegraft, allograft, alone or in combination with any commerciallyavailable bone fusion promoting product. The cage is then inserted intothe midline of the anterior disc space routinely until it is flush orcountersunk relative to the vertebral body above and below. The fourBDFT screws are then inserted into the two middle internalized rostrally(superiorly) and two lateral, caudally (inferiorly) angled screw guides.A drill with or without a drill guide can be used to prepare for screwplacement. This is not absolutely necessary. Because the cage hasinternalized screw guides, self-drilling/self-tapping screws of theappropriately selected lengths can be directly screwed into thevertebral bodies once placed into the internalized drill-guided angledtunnels. The cage's internalized guides, which have internalizedtunnels, direct the screws into the superior and inferior vertebralbodies in the predetermined angle of the internalized tunnels. There isno other angled trajectory other than that which is built into theinternalized screw guide/tunnel of the cage that the screw can beoriented in. Hence there is no absolute need for fluoroscopic guidance.

Once the surgeon is satisfied with the position and placement of thecage, the

BDFT screws can then be locked in their final positions. Then a screwlocking bracket is gently placed on top of the cage with the pliers(FIG. 5) allowing the bracket hooks to snap into the cage inserts. Ifthe surgeon changes his mind intra-operatively, or if in a future datethe construct needs to be removed, the surgeon presses on the side tabswith pliers (FIG. 5) to slightly deform (open) the bracket hooks and canthen easily remove the locking bracket. The locking bracket has severalcycles of use, and thus screws once backed out, can be re-screwed andre-locked. Multiple level placements can be performed including two,three or more levels if necessary.

Implantation of the posterior lumbar intervertebral cage/BDFT screwconstructs (FIG. 4) can be performed via previously described posteriorlumbar interbody fusion (PLIF) or posterior transforaminal lumbarinterbody fusion (TLIF) procedures. The procedures can be performedopen, microscopic, closed tubular or endoscopic techniques. Fluoroscopicguidance can be used with any of these procedures.

After the adequate induction of anesthesia, the patient is placed in theprone position. A midline incision is made for a PLIF procedure, and oneor two parallel paramedian incisions or a midline incision is made forthe TLIF procedure. For the PLIF procedure, a unilateral or bilateralfacet sparing hemi-laminotomy is created to introduce the posteriorlumbar construct into the disc space after a discectomy is performed andthe space adequately prepared.

For the TLIF procedure, after unilateral or bilateral dissection anddrilling of the inferior articulating surface and the medial superiorarticulating facet the far lateral disc space is entered and acircumferential discectomy is performed. The disc space is prepared andthe endplates exposed.

The disc height is measured and a posterior lumbar intervertebralcage/BDFT screw construct (FIG. 4) of the appropriate disc height, widthand depth is selected. The central cavity is packed with bone fusionmaterial, autologous bone graft, allograft, alone or in combination withany commercially available bone fusion promoting product. Then oneconstruct is placed on either right or left sides, or one construct eachis placed into left and right sides. The constructs are inserted suchthey are flush or countersunk relative to the superior and inferiorvertebral bodies. In addition to the central cavities that are packedwith bone product, the intervertebral space in between the constructscan also be packed with bone product for fusion.

The BDFT screws are then inserted into internalized rostrally(superiorly) and caudally (inferiorly) angled screw guides. A drill withor without a drill guide can be used to prepare for screw placement.This is not absolutely necessary. Because the cage has internalizedscrew guides, self-drilling/self-tapping screws of the appropriatelyselected lengths can be directly screwed into the vertebral bodies onceplaced into the internalized drill-guided angled tunnels. The cage'sinternalized guides, which have internalized tunnels, direct the screwsinto the superior and inferior vertebral bodies in the predeterminedangle of the internalized tunnels. There is no other angled trajectoryother than that which is built into the internalized screw guide/tunnelof the cage that the screw can be oriented in. Hence, unlike posteriorplacement of pedicle screws there is no absolute need for fluoroscopicor expensive and cumbersome, frameless stereotactic CT guidance.

Once the surgeon is satisfied with the position and placement of thecage, the BDFT screws can then be locked in their final positions. Thena screw locking bracket is gently placed on top of the cage with thepliers (FIG. 5) allowing the bracket hooks to snap into the cageinserts. If the surgeon changes his mind intra-operatively, or if in afuture date the construct needs to be removed, the surgeon presses onthe side tabs with pliers (FIG. 5) to slightly deform (open) the brackethooks and can then easily remove the locking bracket. The lockingbracket has several cycles of use, and thus screws once backed out, canbe re-screwed and re-locked. Multiple level placements can be performedincluding two, three or more levels if necessary.

The surgical placement of the lumbar facet staples via a posterior facetlumbar staple gun (FIG. 6) is described in the aforementioned relatedapplications. The surgical procedure for these staple embodiments withthis staple gun embodiment is identical to that which has beenpreviously described. The evolutionary advantages of these embodimentsare explained above.

For posterior placement of the cervical facet staples using the cervicalfacet staple gun embodiments (FIGS. 7-8), after the adequate inductionof anesthesia the patient is flipped prone and his head and necksecured. A single midline or two paramedian incisions are made forunilateral or bilateral or multilevel placement of cervical staples.Ultimately the facet joint is exposed. Alternatively and preferably thiscan be performed percutaneously under fluoroscopic guidance with IVsedation. The cervical staple, two or four pronged is loaded either intothe two or four pronged staple gun, is placed on the two articulatingcervical facets, and then stapled into the joint using the staple gun.To achieve modular calibrated fusion, different combinations andpermutations of cervical facet staples can be inserted ranging from asingle unilateral two pronged staple providing a high degree offlexibility to a total of four bilaterally placed four pronged cervicalstaples leading to the highest degree of rigidity per cervical posteriorjoint. Additional bone may or may not be placed in the vicinity tofacilitate permanent and solid fusion. These simplified and economicallyefficient cervical staple guns make this procedure amenable topercutaneous, precise staple placement, as well as contoured staple-boneintegration.

The present inventions may provide effective and safe techniques thatovercome the problems associated with current transpedicular basedcervical, thoracic and lumbar fusion technology, as well as anteriorcervical, thoracic and lumbar plating technology, and for manydegenerative stable and unstable spinal diseases. These inventions couldreplace much pedicle screw, and anterior plating based instrumentationin many but not all degenerative spine conditions.

The speed and simplicity of placement of posterior cervical and lumbarfacet staples, placement of anterior and posterior lumbar intervertebralcage/BDFT screw constructs, and placement of anterior cervical cage/BDFTscrew constructs far exceeds that of current pedicle screw and anteriorspinal plating technology. Furthermore, these devices have markedlysignificantly decreased risk of misguided screw placement and hencedecreased risk of neurovascular injury, and blood loss. In the cervicaland lumbar spines, intervertebral cage/BDFT screw constructs and facetstaples could be applied modularly in different combinations to achievedifferent degrees of rigidity (flexibility). Furthermore, the posteriorcervical and lumbar staple technology is amenable to short same-dayprocedures performed under local/IV anesthesia with a rapid recoverytime. The lumbar and cervical intervertebral cage/BDFT screw constructsall would have decreased recovery time, and more rapid return to worktime compared to pedicle screw, and plating technology. These deviceswith great probability lead to similar if not equal fusion rates, withsubstantially less morbidity, and hence, overall, make them a majoradvance in the evolution of spinal instrumented technology leading toadvances in the compassionate care of the spinal patient.

For example, an aspect of the invention is directed to a method ofinserting a bi-directional fixating transvertebral (BDFT) screw/cageapparatus between a first vertebral body and a second vertebral body,the method including inserting an intervertebral cage into a midline ofa disc space between the first vertebral body and the second vertebralbody until the intervertebral cage is one of flush and countersunkrelative to the first vertebral body and the second vertebral body,inserting a first screw member into a first internal screw guide of theselected intervertebral cage, inserting a second screw member into asecond internal screw guide of the selected intervertebral cage,screwing the first screw member and the second screw member into thefirst vertebral body and the second vertebral body respectively, andlocking the first screw member and the second screw member in theintervertebral cage using a central screw locking lever coupled to theintervertebral cage, wherein the central screw locking lever preventsthe first screw member and the second screw from pulling-out of thefirst internal screw guide and the second internal screw guide.

The central screw locking lever is rotatably coupled to theintervertebral cage, and the locking the first screw member and thesecond screw member in the intervertebral cage includes unlocking thefirst screw member and the second screw member, wherein the unlockingincludes rotating the central screw locking lever with respect to theintervertebral cage from the locked position in which the central screwlocking lever covers and locks the first screw member and the secondscrew member in the intervertebral cage to the unlocked position inwhich the first screw member and the second screw member are exposed.

The central screw locking lever includes a screw locking horizontalbracket, and wherein the locking includes press fitting the screwlocking horizontal bracket on a top of the intervertebral cage such thatthe screw locking horizontal bracket covers and locks the first screwmember and the second screw member in the intervertebral cage. Themethod can further include unlocking the first screw member and thesecond screw member, wherein the intervertebral cage includes hookinsertion slots, wherein the screw locking horizontal bracket includes acover portion extending in a direction of a longitudinal axis of theintervertebral cage and substantially parallel to a top face of theintervertebral cage, the cover portion covering and locking the firstscrew member and the second screw member in the intervertebral cage,side tabs on each end of the cover portion, wherein the side tabs extendin a direction perpendicular to the cover portion along the sides of theintervertebral cage, and wherein the side tabs include bracket hooksextending from the side tabs and lockingly engaging the hook insertionslots of the intervertebral cage, and bracket flexion grips fordeforming the screw locking horizontal bracket, wherein the unlockingincludes applying pressure to the bracket flexion grips to deform thescrew locking horizontal bracket such that the side tabs of the screwlocking bracket move away from the intervertebral cage and release thebracket hooks of the screw locking horizontal bracket from the hookinsertion slots of the intervertebral cage.

While the foregoing disclosure shows illustrative embodiments of theinvention, it should be noted that various changes and modificationscould be made herein without departing from the scope of the inventionas defined by the appended claims. The functions, steps and/or actionsof the method claims in accordance with the embodiments of the inventiondescribed herein need not be performed in any particular order.Furthermore, although elements of the invention may be described orclaimed in the singular, the plural is contemplated unless limitation tothe singular is explicitly stated.

1-31. (canceled)
 32. A intervertebral combination internal screw guideand fixation apparatus configured to be inserted into a disc spacebetween a first vertebral body and a second vertebral body and toprovide fusion of the first vertebral body to the second vertebral bodyvia biological bone fusion and screw fusion, the apparatus comprising:an intervertebral cage including: a top wall, a bottom wall, and twosidewalls defining an open space capable of receiving bone filling forthe biological bone fusion; an internal screw guide having a screwentrance portion and an internal bore portion, wherein the screwentrance portion is larger than and coaxial with the internal bore andis formed at least partially in the top surface of the top wall asviewed from the top, wherein the internal bore portion has an entryopening formed only in a top surface of the top wall as viewed from thetop and has an exit opening formed at least partially in a bottomsurface of the top wall and at least partially in a side surface of thetop wall; a second internal screw guide having a second screw entranceportion and a second internal bore portion, wherein the second screwentrance portion is larger than and coaxial with the second internalbore and is formed at least partially in the top surface of the top wallas viewed from the top, wherein the second internal bore portion has asecond entry opening formed only in the top surface of the top wall asviewed from the top and has a second exit opening formed at leastpartially in the bottom surface of the top wall and at least partiallyin a second side surface of the top wall, and wherein the internal screwguide and the second internal screw guide are angled to orient a firstscrew member and a second member screw bi-directionally in oppositedirections; a first slot on a first outer side of a first sidewall ofthe two sidewalls; a second slot on a second outer side of a secondsidewall of the two sidewalls, wherein the second slot is positionedopposite of the first slot; wherein the first slot is positioned along afirst centerline axis that bisects the first side wall and is positionednearer a top of the intervertebral cage than a bottom of theintervertebral cage, wherein the second slot is positioned along asecond centerline axis that bisects the second side wall and ispositioned nearer the top of the intervertebral cage than the bottom ofthe intervertebral cage, wherein the side surface and the second sidesurface of the top wall are patterned with a plurality of surfacefeatures to create rough side surfaces, wherein at least some of theplurality of surface features are positioned on the side surface betweenthe top wall and the exit opening, and wherein the top wall, the bottomwall, and the sidewalls are integrally formed and the open space forreceiving bone graft material extends continuously from an inner surfaceof the first sidewall to an inner surface of the second sidewall andextends continuously from an inner surface of the top wall to an innersurface of the bottom wall; a first screw having a first screw head anda first screw threaded portion, wherein the first screw is sized to bepositioned in the internal screw guide with the first screw head in thescrew entrance portion; a second screw having a seconds screw head and aseconds screw threaded portion, wherein the second screw is sized to bepositioned in the second internal screw guide with the second screw headin the second screw entrance portion; and a screw locking bracket havinga first end portion sized and positioned to be inserted in the firstslot, a second end portion sized and positioned to be inserted in thesecond slot and a central portion extending between the first endportion and the second end portion, wherein when the screw lockingbracket is connected to the intervertebral cage with the first endportion in the first slot and the second end portion in the second slot,the central portion partially blocks the screw entrance portion and thesecond screw entrance portion so as to retain the first and secondscrews in the internal screw guide and the second internal screw guidewhile leaving at least a portion of the screw entrance portion and thesecond screw entrance portion at least partially exposed.
 33. Theapparatus of claim 32, wherein the screw locking bracket contacts boththe first and second screw heads when the screw locking bracket isconnect to the intervertebral cage.
 34. The apparatus of claim 32,wherein the screw locking bracket comprises a first hook at the firstend portion that is sized to fit in the first slot and a second hook atthe second end portion that is sized to fit in the second slot.
 35. Theapparatus of claim 32, wherein the first end portion and the second endportion extend in a direction that is substantially perpendicular to thecentral portion.
 36. The apparatus of claim 32, wherein the plurality ofsurface features on the side surface and the second side surface arepatterned all the way next to the top surface of the top wall so as tobe adjacent the top surface of the top wall.
 37. The apparatus of claim32, and further comprising means for fusing superior and inferiorvertebral bodies in conjunction with the intervertebral cage.
 38. Theapparatus of claim 32, wherein the intervertebral cage is sized andconfigured for use in a patient's lumbar spine, the apparatus furthercomprising means for fusing superior and inferior lumbar vertebralbodies in conjunction with the intervertebral cage.
 39. The apparatus ofclaim 32, wherein at least some of the plurality of surface features arepositioned on the second side surface between the top wall and thesecond exit opening.
 40. The apparatus of claim 32, wherein the screwlocking bracket comprises a first hook at the first end portion thatcurves inward to engage the first slot and a second hook at the secondend portion that curves inward to engage the second slot.
 41. Theapparatus of claim 32, wherein the screw locking bracket comprises meansto slightly open the screw locking bracket.
 42. A intervertebralcombination internal screw guide and fixation apparatus configured to beinserted into a disc space between a first vertebral body and a secondvertebral body and to provide fusion of the first vertebral body to thesecond vertebral body via biological bone fusion and screw fusion, theapparatus comprising: an intervertebral cage including: a top wall, abottom wall, and two sidewalls defining an open space capable ofreceiving bone filling for the biological bone fusion; an internal screwguide having a screw entrance portion and an internal bore portion,wherein the screw entrance portion is larger than and coaxial with theinternal bore and is formed at least partially in the top surface of thetop wall as viewed from the top, wherein the internal bore portion hasan entry opening formed only in a top surface of the top wall as viewedfrom the top and has an exit opening formed at least partially in abottom surface of the top wall and at least partially in a side surfaceof the top wall; a second internal screw guide having a second screwentrance portion and a second internal bore portion, wherein the secondscrew entrance portion is larger than and coaxial with the secondinternal bore and is formed at least partially in the top surface of thetop wall as viewed from the top, wherein the second internal boreportion has a second entry opening formed only in the top surface of thetop wall as viewed from the top and has a second exit opening formed atleast partially in the bottom surface of the top wall and at leastpartially in a second side surface of the top wall, and wherein theinternal screw guide and the second internal screw guide are angled toorient a first screw member and a second member screw bi-directionallyin opposite directions; a first slot extending at least partially into afirst sidewall of the two sidewalls; a second slot extending at leastpartially into a second sidewall of the two sidewalls, wherein thesecond slot is positioned opposite of the first slot; wherein the firstslot is positioned along a first centerline axis that bisects the firstside wall and is positioned nearer a top of the intervertebral cage thana bottom of the intervertebral cage, wherein the second slot ispositioned along a second centerline axis that bisects the second sidewall and is positioned nearer the top of the intervertebral cage thanthe bottom of the intervertebral cage, wherein the side surface and thesecond side surface of the top wall are patterned with a plurality ofsurface features to create rough side surfaces, wherein at least some ofthe plurality of surface features are positioned on the side surfacebetween the top wall and the exit opening, and wherein the top wall, thebottom wall, and the sidewalls are integrally formed; a first screwhaving a first screw head and a first screw threaded portion, whereinthe first screw is sized to be positioned in the internal screw guidewith the first screw head in the screw entrance portion; a second screwhaving a seconds screw head and a seconds screw threaded portion,wherein the second screw is sized to be positioned in the secondinternal screw guide with the second screw head in the second screwentrance portion; and a screw locking bracket having a first end portionsized and positioned to be inserted in the first slot, a second endportion sized and positioned to be inserted in the second slot and acentral portion extending between the first end portion and the secondend portion, wherein when the screw locking bracket is connected to theintervertebral cage with the first end portion in the first slot and thesecond end portion in the second slot, the central portion partiallyblocks the screw entrance portion and the second screw entrance portionso as to retain the first and second screws in the internal screw guideand the second internal screw guide while leaving at least a portion ofthe screw entrance portion and the second screw entrance portion atleast partially exposed.
 43. The apparatus of claim 32, wherein theplurality of surface features on the side surface and the second sidesurface are patterned all the way next to the top surface of the topwall so as to be adjacent the top surface of the top wall.
 44. Theapparatus of claim 32, and further comprising means for fusing superiorand inferior vertebral bodies in conjunction with the intervertebralcage.
 45. The apparatus of claim 32, wherein the intervertebral cage issized and configured for use in a patient's lumbar spine, the apparatusfurther comprising means for fusing superior and inferior lumbarvertebral bodies in conjunction with the intervertebral cage.
 46. Theapparatus of claim 32, wherein at least some of the plurality of surfacefeatures are positioned on the second side surface between the top walland the second exit opening.
 47. The apparatus of claim 32, wherein thescrew locking bracket comprises means to slightly deform the screwlocking bracket to remove the screw locking bracket from theintervertebral cage.
 48. The apparatus of claim 47, wherein the meanscomprises a flexion portion of the screw locking bracket.
 49. Theapparatus of claim 32, wherein the screw locking bracket contacts boththe first and second screw heads when the screw locking bracket isconnect to the intervertebral cage.
 50. The apparatus of claim 32,wherein the screw locking bracket comprises a first hook at the firstend portion that is sized to fit in the first slot and a second hook atthe second end portion that is sized to fit in the second slot.
 51. Amethod of inserting a bi-directional fixating transvertebral (BDFT)screw/cage apparatus between a first vertebral body and a secondvertebral body, the method including: inserting an intervertebral cageinto a midline of a disc space between the first vertebral body and thesecond vertebral body until the intervertebral cage is one of flush andcountersunk relative to the first vertebral body and the secondvertebral body, wherein the intervertebral cage includes: a top wall, abottom wall, and two sidewalls defining an open space capable ofreceiving bone filling for the biological bone fusion; an internal screwguide having a screw entrance portion and an internal bore portion,wherein the screw entrance portion is larger than and coaxial with theinternal bore and is formed at least partially in the top surface of thetop wall as viewed from the top, wherein the internal bore portion hasan entry opening formed only in a top surface of the top wall as viewedfrom the top and has an exit opening formed at least partially in abottom surface of the top wall and at least partially in a side surfaceof the top wall; a second internal screw guide having a second screwentrance portion and a second internal bore portion, wherein the secondscrew entrance portion is larger than and coaxial with the secondinternal bore and is formed at least partially in the top surface of thetop wall as viewed from the top, wherein the second internal boreportion has a second entry opening formed only in the top surface of thetop wall as viewed from the top and has a second exit opening formed atleast partially in the bottom surface of the top wall and at leastpartially in a second side surface of the top wall, and wherein theinternal screw guide and the second internal screw guide are angled toorient a first screw member and a second member screw bi-directionallyin opposite directions; a first slot extending at least partially into afirst sidewall of the two sidewalls; a second slot extending at leastpartially into a second sidewall of the two sidewalls, wherein thesecond slot is positioned opposite of the first slot; wherein the firstslot is positioned along a first centerline axis that bisects the firstside wall and is positioned nearer a top of the intervertebral cage thana bottom of the intervertebral cage, wherein the second slot ispositioned along a second centerline axis that bisects the second sidewall and is positioned nearer the top of the intervertebral cage thanthe bottom of the intervertebral cage, wherein the side surface and thesecond side surface of the top wall are patterned with a plurality ofsurface features to create rough side surfaces, wherein at least some ofthe plurality of surface features are positioned on the side surfacebetween the top wall and the exit opening, and wherein the top wall, thebottom wall, and the sidewalls are integrally formed; and inserting afirst screw into the internal screw guide of the intervertebral cage;inserting a second screw into the second internal screw guide of theintervertebral cage; screwing the first screw and the second screw intothe first vertebral body and the second vertebral body respectively; andlocking the first screw and the second screw in the intervertebral cageusing a screw locking bracket coupled to the intervertebral cage bypositioning a first end portion of the screw locking bracket in thefirst slot, a second end portion of the screw locking bracket in thesecond slot and a central portion of the screw locking bracket extendingbetween the first end portion and the second end portion across at leastpart of the top surface of the top wall such that the central portionpartially blocks the screw entrance portion and the second screwentrance portion so as to retain the first and second screws in theinternal screw guide and the second internal screw guide while leavingat least a portion of the screw entrance portion and the second screwentrance portion at least partially exposed.